Updated 10 March 2017

Pancreatic cancer

Summary

Cancer of the pancreas is also called carcinoma of the pancreas, or pancreatic cancer.

Cancer occurs when for some reason; cells begin to divide without order or control.

Because of the location of the pancreas, cancer may grow for some time before it causes symptoms.

Cancer of the pancreas can also cause nausea, loss of appetite, weight loss, and weakness.

This disease can be cured only when it is found at an early stage, before it has begun to spread.

Various treatments can be considered for this disease.

Description

Worldwide, cancer of the pancreas is responsible for about 5 percent of cancer deaths every year. It is often referred to as the “silent disease” because symptoms are few and non-specific, leading to late diagnosis in the majority of cases.

Cancer of the pancreas tends to affect people over the age of 50, and most sufferers are aged 65 to 80 at the time of diagnosis. Men are at slightly higher risk than women.

The pancreas is located in the central upper abdomen. It is surrounded by the stomach, intestines and other organs. The pancreas is about six inches long and is shaped like a long, flattened pear – wide at one end and narrow at the other. It is divided into three parts – the wide part is called the head, the narrow end is the tail, and the middle section is called the body. It has a duct running down the centre.

The pancreas is a gland that has two main functions: it makes pancreatic juices and it produces several hormones, including insulin. Pancreatic juices contain proteins called enzymes that help digest food. The pancreas releases these enzymes into a system of ducts, as they are needed. The main pancreatic duct joins the common bile duct from the liver and gallbladder. (The common bile duct carries bile, a fluid that helps digest fat.) Together these ducts form a short tube that empties into the duodenum, which is the first section of the small intestine.

Pancreatic hormones help the body use or store the energy that comes from food. For example, insulin helps control the levels of glucose (a source of energy) in the blood. The pancreas releases insulin and other hormones when they are needed. They enter the bloodstream and travel throughout the body.

Cancer occurs when for some reason cells begin to divide without order or control. They may invade and destroy the tissue around them. Cancer cells can also break away from the primary (original) tumour and enter the bloodstream or the lymphatic system. This process is the way cancer spreads to form new tumours in other parts of the body. These new tumours are called metastases.

Several types of cancer can develop in the pancreas. Most pancreatic cancers begin in the ducts that carry pancreatic juices, but a very rare type of pancreatic cancer may begin in the cells that produce insulin and other hormones. These cells are called islet cells, or the islets of Langerhans. Cancers that begin in these cells are called islet-cell cancers. As pancreatic cancer grows, the tumour may invade organs that surround the pancreas, such as the stomach or small intestine. Cells may also break off from the tumour and travel to the lymph nodes or to other organs like the liver or lungs. This usually only occurs when the cancer is quite large.

Causes and risk factors

Despite extensive studies, no definite cause for pancreatic cancer has been identified. There are, however, several identifiable risk factors. A risk factor is something which may increase a person’s chances of contracting the cancer, but which does not directly cause it. Several of these are mentioned below:

Smoking has a definite association with pancreatic cancer, and cigarette smokers develop this disease two to three times more often than non-smokers. Smoking cessation reduces the risk by about 30 percent.

Diet is important. Diets high in red meat and animal fats have been shown to be associated with pancreatic cancer, while diets high in fresh fruit and vegetables help to prevent the disease.

Diabetes. Having diabetes is another risk factor. People who have diabetes develop pancreatic cancer about twice as often as non-diabetics. This refers mainly to patients with insulin-dependent diabetes, especially if it was diagnosed before the age of 40.

Chronic inflammation of the pancreas and a previous history of upper gastro-intestinal surgery have also been shown in some studies to predispose to pancreatic cancer.

Occupational exposure to petroleum and certain chemicals – some studies suggest that this may increase the risk of pancreatic cancer. These possible links have not been proven, but workers should follow the safety rules provided by employers.

Gender – men get pancreatic cancer more frequently than women.

Race – Africans are more frequently affected than Caucasians and Asians.

Family history – a first-degree relative with the disease triples the risk. A family history of colon or ovarian cancer also increases the risk.

Symptoms

Because of the location of the pancreas, cancer may grow for some time before it causes symptoms. When symptoms do appear, they may be so vague that they are ignored at first. For these reasons, pancreatic cancer is hard to find early. In many cases, the cancer has spread outside the pancreas by the time it is found.

When symptoms do appear, they depend on the location and size of the tumour. If the tumour is located in the head of the pancreas, it may block the common bile duct so that bile cannot pass into the intestines. This causes the skin and the whites of the eyes to become yellow and the urine to become dark. This condition is called jaundice.

Cancer starting in the body or tail of the pancreas often causes no symptoms at all until it grows and spreads. This causes pain, which may be felt in the upper abdomen and sometimes spreads to the back. The pain may become worse after the person eats or lies down. Leaning forward typically relieves the pain.

Cancer of the pancreas can also cause nausea, loss of appetite, weight loss and weakness.

Islet-cell cancer can cause the pancreas to produce and secrete too much insulin or other hormones. When this happens, the person may feel weak or dizzy and may have chills, muscle spasms or diarrhoea.

All the symptoms mentioned above may be caused by cancer, but are more commonly caused by other, less serious conditions. Persistence of any of these symptoms should alert the patient to seek medical attention. Only special investigations by a doctor can lead to the correct diagnosis.

Diagnosis

To find the cause of a person's symptoms, the doctor will ask for a detailed medical history and perform a physical exam. This may include blood, urine and stool tests.

He or she may order various special investigations, including:

An upper-GI series (sometimes called a barium meal). This is a series of X-rays of the upper digestive system, taken after the patient has swallowed a barium solution. The barium shows an outline of the digestive organs on the X-rays.

A CT scan. This uses a computerised X-ray machine to show images of the internal organs. The patient lies on a bed which moves through a circular hole as the machine takes pictures. He or she may be asked to drink a special substance prior to the scan – this will show up the bowel more easily.

An MRI scan. This uses a powerful magnet linked to a computer. The MRI machine is very large, with space for the patient to lie in a tunnel inside the magnet. The machine measures the body's response to the magnetic field, and the computer uses this information to make detailed pictures of areas inside the body.

Ultrasonography. This uses high-frequency sound waves that cannot be heard by humans. A small instrument sends sound waves into the patient's abdomen. These cannot be felt, but the echoes bounce off internal organs, creating a picture called a sonogram. Healthy tissues and tumours produce different echoes. This investigation is good for lean people, but fat tissue may distort the signal.

ERCP (endoscopic retrograde cholangiopancreatography). This is a method for taking X-rays of the common bile duct and pancreatic ducts. The doctor passes a long, flexible tube (endoscope) down the throat, through the stomach, and into the small intestine. Dye is then injected into the ducts and X-rays are taken. This procedure is usually done under sedation.

PTCA (percutaneous transluminal coronary angioplasty). A thin needle is put into the liver through the skin on the right side of the abdomen. Dye is injected into the bile ducts in the liver, so blockages can be seen on X-rays.

Angiography. This involves injecting dye into blood vessels so that they show up on the X-rays.

A biopsy of a suspicious lesion or washings of the ducts (done via ERCP) will provide a definitive diagnosis.

Blood tests in the form of tumour markers may also be requested.

The information from all these tests is used to help make a diagnosis, and also to provide information about how advanced the disease is. This is called staging. In cancer of the pancreas, three stages of the disease are recognised:

Localised disease – where the disease is limited to the pancreas alone. This can usually be treated with surgery.

Locally advanced disease – where the cancer has spread from the pancreas itself to involve the organs adjacent to it.

Metastatic disease – where the cancer has spread in the blood to other organs far from the pancreas, such as the lungs.

The final diagnosis is made after a biopsy is done. This is usually under ultrasound guidance, where a needle is inserted into the tumour and some cells removed.

Preparation for doctor’s visit

Many people with cancer want to learn all they can about their disease and their treatment choices, so they can take an active part in decisions about their medical care. When someone is diagnosed with cancer, shock, denial and anxiety are natural reactions. These feelings may make it difficult for them to think of all the questions that they want to ask the doctor. It often helps to make a list. Some patients also want to have a family member or friend with them when they talk to the doctor – to take part in the discussion, to take notes, or just to listen.

Patients do not need to ask all their questions or remember all of the answers at one time. They will have other chances to ask the doctor to explain things and to get more information. These are some questions a patient may want to ask the doctor before treatment begins:

What is my diagnosis?

What is the stage of the disease?

What are my treatment choices? What does each treatment involve? Which do you recommend? Why?

What are the risks and possible side effects of each treatment?

What are the chances that the treatment will be successful?

Treatment

Cancer of the pancreas is usually difficult to treat because of its late presentation. This disease can be cured only if found at an early stage. Cure cannot be achieved in patients with locally advanced or in patients with evidence of distant spread. However, even when the disease is advanced, treatment can improve the quality of the patient’s life by controlling the symptoms and complications of the cancer. People with pancreatic cancer are often treated by a team of specialists which may include surgeons, medical oncologists, radiation oncologists and endocrinologists. The choice of treatment depends on the type of cancer, the stage of the cancer and the general health of the patient. Of course, the patient has the final say in the treatment proposed.

Cancer confined to the pancreas or with minimal local spread, may be treated with surgery. This is often used in combination with chemotherapy and radiation therapy. Some oncologists prefer to give combined chemo- and radiation therapy for two to three months prior to surgery, while others prefer to give it afterwards. In some centres, radiation may also be given during the operation.

Curative surgery is major surgery, and is only done by a specialist surgeon. The Whipple procedure involves removal of the head of the pancreas as well as the duodenum, part of the stomach, bile duct and nearby lymph nodes. Cancer in the body or tail of the pancreas usually requires a total pancreatectomy, which is removal of the entire pancreas, as well as duodenum, gallbladder, bile duct, spleen and lymph nodes. Unfortunately during surgery doctors frequently discover that the cancer is more advanced than it had appeared on the scans, so the operation is stopped. Such major surgery is not advised unless the entire tumour can be removed.

The length of time it takes to recover from an operation varies for each person. During recovery from surgery, a patient's diet and weight are checked carefully. At first, patients may be fed only liquids and may be given extra nourishment via a drip. Solid foods are introduced gradually. Frequently after surgery, the levels of pancreatic hormones and enzymes are inadequate. Difficulty in digestion and maintaining blood glucose levels may arise. The doctor can suggest an appropriate diet and prescribe drugs to relieve symptoms. These may include enzymes and hormones such as insulin.

See below for more information about nutrition for people with cancer.

If complete removal of the cancer is not possible, less radical surgery can help to relieve symptoms due to blockage of the bowel or bile duct. In these cases a bypass procedure is performed, or a stent inserted.

Locally advanced disease – In these cases surgery is not a curative option. It may be used to relieve obstructive symptoms as mentioned above, but it is only a palliative measure. The main treatment in these cases would be radiation and chemotherapy – either separately or together. These have been shown in several studies to greatly relieve symptoms and improve quality of life.

Metastatic disease – Once pancreatic cancer has spread to distant sites in the body it cannot be cured. Several studies have looked at ways of trying to improve the quality of life for patients who have such advanced disease. Radiation may help to relieve pain, and several types of chemotherapy have been shown to improve appetite and relieve pain. Unfortunately, these treatments do not improve life expectancy. Despite this, the patients who received these treatments in trials reported a definite benefit when compared to patients who did not receive treatment.

Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing and dividing. Like surgery, radiation therapy is local therapy; the radiation can affect cancer cells only in the treated area. The patient lies on a bed and a machine, similar to an X-ray machine, is used to aim the radiation beam at the area defined by the radiation oncologist. Doctors may use radiation therapy before surgery to shrink a tumour so that it is easier to remove, or after surgery to destroy cancer cells that may remain in the area. In most cases, patients receive radiation treatment as an outpatient. The treatments are short – usually lasting only minutes – but must be given daily, four or five times a week. The course may be as short as three weeks or last for several weeks, depending on what is being treated.

Side effects of radiation depend on the dose given and the area treated. Patients receiving radiation tend to get very tired, especially towards the end of the treatment.

The skin in the treatment area may become itchy and red. The patient will be asked not to wash or rub this area during treatment or to use any creams or lotions without discussing this with the doctor first, as they may exacerbate the problem. The skin will heal after radiation, but there may be permanent “bronzing” of this area. There will also be hair loss (in the treated area only).

Radiation over the abdomen can also cause nausea and vomiting as well as diarrhoea and pain on swallowing. Medication can be given to combat these problems, and they usually disappear at the end of the treatment.

Chemotherapy is the use of drugs to kill cancer cells. It may be given alone or together with radiation therapy – either before or following surgery in early cases, or to relieve symptoms of the disease if the cancer cannot be removed. The doctor may use one drug or a combination of drugs.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most anticancer drugs are given by injection into a vein (IV); some are given by mouth. Chemotherapy is a systemic therapy – meaning that the drugs flow through the body in the bloodstream. Usually a person receives chemotherapy as an outpatient (at the hospital, or at the doctor’s office). However, a short hospital stay may be needed, depending on the patient’s general health and on which drugs are used.

The side effects of chemotherapy depend on the specific drugs and doses used. They also vary greatly from person to person. Before starting chemotherapy your doctor will explain to you fully the side effects that you can expect. Most chemotherapy drugs affect all rapidly dividing cells in the body. That means that the normal cells most commonly affected are the bone marrow cells, the hair root cells, and the cells lining the digestive tract. For this reason, the blood count must be monitored before every cycle of chemotherapy. The number of red blood cells, white blood cells and platelets is monitored, as drops in any of these counts can lead to problems. Many, but not all, of the chemotherapy drugs may cause hair loss. Also, during the first week or so after the chemotherapy, mouth ulcers, nausea and vomiting or diarrhoea may develop. The patient will be warned if this is to be expected with the proposed treatment.

Pain control

Pain is a common problem for people with pancreatic cancer, especially when the cancer grows outside the pancreas and presses against nerves and other organs. However, this can usually be controlled. It is important for patients to report their pain so the doctor can take steps to help relieve it.

There are several ways to control pain caused by pancreatic cancer. In most cases the doctor prescribes medicine; sometimes a combination of pain medicines is needed. Pain relief medication may make some people drowsy and constipated, but resting and taking laxatives may relieve this. In some cases, pain medicine is not enough and the doctor may need to use other types of treatment that affect nerves in the abdomen. For example, the doctor may inject alcohol into the area around certain nerves to block the feeling of pain. This injection can be done during surgery or by using a long needle inserted through the skin into the abdomen. This procedure rarely causes problems and usually works.

Sometimes the surgeon cuts nerves in the abdomen to block the feeling of pain. In addition, radiation therapy can help relieve pain by shrinking the tumour.

Occasionally, it may be necessary to insert an epidural catheter through which pain medication can be delivered daily. This involves an injection rather like a lumbar puncture, where a small plastic tube is placed into the space around the spinal cord, and medication is slowly injected throughout the day by means of a syringe driver which is carried in the pocket.

Second opinion

A diagnosis of cancer has major implications. Many patients find the diagnosis difficult to accept, especially if their symptoms have not been sudden and obvious. In this case, the patient may like to obtain a second opinion. The family doctor may be able to suggest a second oncologist to consult. If a second pathology opinion is needed, the oncologist can arrange this. Alternatively, cancer societies or the local hospital can help the patient find a second opinion.

Clinical trials

Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments, and many people with cancer take part in these trials. In some clinical trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group.

People who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science. In clinical trials for pancreatic cancer, doctors are studying different ways of giving radiation therapy, aiming the rays at the cancer during surgery or implanting radioactive material in the abdomen. They are also exploring new ways of giving chemotherapy, new drugs and drug combinations, biological therapy, and new ways of combining various types of treatment. Some trials are designed to study ways to reduce the side effects of treatment and to improve quality of life. People interested in taking part in a trial should discuss it with their doctor.

Nutrition

Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and maintain strength. Proper nutrition often helps people feel better and have more energy. However, some people with cancer find it hard to eat well, and may lose their appetite. Common side effects of treatment such as nausea, vomiting or mouth sores can make eating difficult. Often foods taste different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.

Cancer of the pancreas and its treatment may interfere with the production of pancreatic enzymes and insulin. As a result, patients may have problems digesting food and maintaining the proper blood sugar level. They may need to take medicines to replace the enzymes and hormones normally produced by the pancreas. These medicines must be given in just the right amount for each patient. The doctor will watch the patient closely and adjust the doses or suggest diet changes when needed. Careful planning and check-ups are important to help avoid nutrition problems leading to weight loss, weakness and lack of energy.

Doctors, nurses and dieticians can offer advice on how to eat well during cancer treatment.

Follow-up

Regular follow-up examinations are very important after treatment for pancreatic cancer. The doctor will continue to check the person closely, so that if the cancer returns or progresses, it can be treated. Checkups may include a physical examination; blood, urine and stool tests; chest X-rays and CT scans.

People taking medicine to replace pancreatic hormones or digestive juices need to see their doctor regularly, so the dose can be adjusted if necessary. Also, it is important for the patient to let the doctor know about pain or any changes or problems that occur.

Support

Living with a serious disease is not easy. People with cancer and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services. The Cancer Association of South Africa and the Hospice Palliative Care Association of SA can help provide both. Early contact with one or both of these organisations is suggested, and your doctor can provide the details. Worries about tests, treatments, hospital stays and medical bills are common. Doctors, nurses and other members of the health care team involved in these organisations can talk to patients and their families about these concerns. Meeting with a social worker, counsellor or a religious leader also can be helpful to those who want to talk about their feelings or discuss their concerns.

Cancer patients and their families may want to know what the future holds. Sometimes they use statistics to try to predict what may happen. It is important to remember that statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to a particular patient, because no two patients are alike, and treatments and responses vary greatly. The doctor who takes care of the patient is in the best position to talk about the person's outlook (prognosis).

Friends and relatives can be very supportive. Also, many people find it helpful to discuss their concerns with others who have cancer. People with cancer often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each patient is different. Treatment and ways of dealing with cancer that work for one person may not be right for another – even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

Often a social worker at the hospital or clinic can suggest groups that provide emotional support or that help with rehabilitation, financial aid, transportation or home care.

Prevention

The best preventative measure is not to smoke and to follow a healthy lifestyle and diet. People who think they may be at risk for pancreatic cancer should discuss this concern with their doctor. The doctor may be able to suggest ways to reduce the risk and can suggest an appropriate schedule of checkups.

Reviewed by Dr Ashraf Wadee, medical oncologist at the University of the Witwatersrand and the Wits Donald Gordon Medical Centre, April 2010

Ask the Expert

CANSA’s purpose is to lead the fight against cancer in South Africa. Its mission is to be the preferred non-profit organisation that enables research, educates the public and provides support to all people affected by cancer. Questions are answered by CANSA’s Head of Health Professor Michael Herbst. For more information, visit cansa.org.za.

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